the obligatory cheesy entry

It was a good weekend on call. 2 of my patients died and a

further 2 came close - but it's not about the mortality or the

sickness. I guess it was good because I learned loads, got to put

some knowledge (previously classed in my memory as 'obscure')

into practice, with the end result of several grateful relatives

for a change. The challenge, as they say, is to "heal the sick

and comfort the dying" - and not get the two mixed up! Also, some

things are best not mentioned to cheesed off relatives - such as

the real reason I took 2 hours to come and speak to them.

(Because I am the only doctor covering 6 medical wards!)
****
LJ is a 60 year-old lady with terminal lung cancer. I'd first met

her by chance about a week ago, because she had come in for a

neurolytic block (injection of phenol to destroy the nerve

supplying a painful area-normally an outpatient procedure), and

had been so short of breath afterward that she had to stay in

hospital overnight. As the on-call doctor, I was asked to see

her. The anaesthetist who had performed the block had thought of

the possible complications- pneumothorax (a punctured lung) and

paralysis, but a check x-ray showed no pneumothorax, and her

chest expansion was symmetrical. When I listened to her chest,

she was extremely wheezy, but denied having asthma or ever having

been a smoker. I prescribed some nebulisers. She stuck in my mind

because of something quite silly- the nurses hadn't removed her

red nail polish, so the pulse oximeter readings were completely

useless. I guess I would have taken an arterial blood sample

anyway, but I was frustrated that the ward didn't have any nail

polish remover. It took about 4 attempts to get an arterial

sample. She screamed every time the needle went into her wrist,

and kept moaning for "Eddy", the elderly man I assumed was her

husband. Anyhow, her saturations improved with the nebulisers and

oxygen.

I didn't see her again for more than a week, and presumed she had

gone home. Yesterday I was bleeped to say LJ was on a different

ward, and her heart rate was 170/min (nearly 3 times as fast as

normal) and she was drenched in sweat, with a temperature of 38.

I instructed the nurse to take blood for various tests, and to

give her some paracetamol. When I arrived on the ward, she looked

dreadful, slumped over and dribbling from nose, mouth, hair. The

front of her nightdress was covered in vomit and she had wet the

bed. She shook her head when asked if she had pain in her chest

or tummy. Her pulse was thready, even at the femorals. I went for

the biggest cannula I could find (still feeling trigger-happy

from inserting two greys into a lady who nearly bled to death

from a duodenal ulcer the day before - but that is another

story!) and got the nurse to push in a litre of saline as quickly

as it would run. For all that, her pulse dropped to - 120. Not

good. I was convinced at this point that she might die, so I had

the nurse contact her son. I had her cleaned up and sat up, the

oxygen turned up, another bag of saline run. I prescribed some

antibiotics to cover a possible aspiration pneumonia. She now

seemed a bit more stable, so i left the ward as my bleep had gone

off about 8 times, including a call about a man in renal failure

(as he hadn't passed any urine for 18 hours) on the other side of

the hospital.

Her son, *Joe, arrived about 2 hours later. I got him into the

ward's quiet room, and tried to impress upon him the seriousness

of the situation. Although he seemed to understand the terminal

nature of her underlying illness, he still had rather unrealistic

expectations of the outcome. Eventually, I said "if your mother

were to stop breathing and her heart were to stop, would you want

us to do everything to bring her back to life?" At this he became

tearful. He paused. Nodded. "yes, of course," he sobbed. I paused

for a bit, then left to let him gather his thoughts. It felt

cruel, but I'd rather paint a grim picture and have them be

pleased when the outcome is better than expected. (rather than

the converse!)

Called away again. I returned to see him standing by her side,

shaking her. "Mom!" She wasn't opening her eyes. She had

definitely been conscious in the morning, despite being in

extremis. I peeled her eyelids back and sure enough the pupils

were pinpoint. Her dehydration had probably caused a build-up of

oxycodone. I got the nurse to draw up some naloxone. "What's that

stuff?" Joe asked, suspiciously. I explained as best I could, and

started to inject it (see entry below - "a suicide, maybe"). She

came round with a jolt. Joe was visibly relieved, but his face

soon fell when she looked him in the eye and said, "I want them

to stop." "Stop what, mom?" "All this," she said, holding up her

arms, which were covered in lines and monitoring equipment.

Oops, have to go head to the airport soon! to cut a long story

short, she survived to see another day. Also, it turned out that

Eddy and Joe are not on speaking terms as Eddy is his step-dad.

And I am going on holiday so I will never know the outcome - will

Joe and Eddy come to accept that intensive care, CPR etc are not

in LJ's best interest? And so on. Every on-call is a bit like

starting a dozen books and never finishing them.

"Don't live to 101, I don't advise it..."

Edith* has silky white hair and bright, gray-green eyes. Her voice is low and raspy and posh, and larger than you would expect from such a tiny lady. She is very deaf, and on close questioning, is not entirely lucid. But she puts up an expert front - "..and are you one of the doctors? Did you have to train for many years?" "..I'm a hundred and 2 months. Don't live to 101...." she smiles wryly. She came into hospital as her GP thought she wasn't quite herself and looked pale. Her haemoglobin was 4.9 (normal >11) though there was no history of bleeding. We gave her a blood transfusion and some iron tablets. She looks a bit pinker now, but where do we go from here? How far do you go looking for a cause of anaemia in someone who is 101?

...but I don't feel rested

managed some proper sleep last night for the first time in about a week. I can't remember if I've mentioned this in a blog entry before, the Work Nightmare. It's not a proper nightmare in that it isn't particularly terrifying, and certainly does not make you wake up in a cold sweat. Rather (and cruelly), it doesn't wake you up at all - just lets you lie inert while a bland continuation of the day's events at work plays on. Ward rounds, discharge letters, cannulas, deaths... And you wake up exhausted, as if you havn't had any sleep at all, and then you have to get up and go to work again. I think I need a holiday.

presenting... my new picture blog!

in the interests of keeping work separate from real life, i suppose. a one-off link, add it to your bookmark list!

Liverpool v. Juventus

(alternatively titled 'doctors do have a life outside hospital').
quite surprisingly the first game I have ever watched at the pub. 0-0, by the way, just to emphasise the pointlessness of it all. I have no clue about the offside rule, and at the end of the game my only comments were "well, the last 10 minutes of that was actually quite good" - Ranj was unimpressed, and has taken it upon himself to educate me on the appreciation of the beautiful game. Still, I have to admit that its much better in the pub than in your own living room - nothing like 20 simultaneous commentaries from various corners of the room, and people jeering, shouting and clapping at the screen, jumping up in unison at almost-goals.

me-just testing

suicide concluded

phonecall to the coroner today. Mrs. K died on Friday night. So she got her way; but something tells me she didn't know she would be subject to an autopsy (for a graphic description, see my earlier entry ('nausea'). So much for RIP.

a suicide, maybe

...too lazy to try and make this entry reader-friendly, so here goes:
80 year-old woman took 75 GRAMS of tramadol - thats more than 100 tablets- she had obviously been hoarding them for ages. 'Doctor! she's having a fit!' by the time i got there she was lying still, looked pretty much dead, had a smile on her face. the sats monitor was bleeping - sats of 83 - possibly normal for her as she had advanced emphysema and usually had oxygen at home. airway was fine, nasopharyngeal in situ. got the nurse to turn it up all the same- then did a blood gas - first time i've seen a CO2 retainer- so had to turn it baack down again. They always go on about them in textbooks. left her to attend to other patients. bleeped by the nurse - "the patient's daughters have arrived, they want to speak to a doctor." oh no. her suicide note was signed "by the way, I am in my right mind. Love, M (member (lapsed) of the Euthanasia Society)" I wondered if perhaps her daughters were Euthanasia Society members too. or maybe firece opponents? afterall, they had called the police when she had refused to come to hospital. Her daughter was quite calm and collected. I think now that i didn't paint a bleak enough picture. i mean, being realistic, she will almost certainly be dead by monday. even if she lives she will be severely brain-damaged. Her breathing slowed to 8 resps a minute. tried to get a nurse to give some more naloxone. both nurses tied up with another dying patient. finally, exesperated, i said "julie, if you could just get me the naloxone, i'll draw it up and inject it myself" julie is one of the nicer nurses to she opened the cabinet and gave me an ampoule. the IV drugs book said to inject it slowly. good thing i followed that instruction. the stuff works fast. before i had injected the 2mls or so, her breathing had normalised. i left her. and now it is the weekend.

The giraffe and the relly and me

I am so fed up of patients dying on me (though Susie*, one of the

nurses, pointed out that they die on everyone, not just me). But

I'm the one who usually gets the job of examining the body after

death (before the nurses have cleaned up the vomit and closed the

eyes), and then I have to face the relatives. Paticularly at

weekends, when it's either the house officer (i.e. doctor less

than a year out of med school) or nobody at all.

I clipped *Tommy Peters' obituary out of the Reading Chronicle

yesterday, just to make him seem more human to me again. Mr.

Peters was an 87 year-old man with known heart failure, and he

had either acquired some kind of pneumonia, or his heart had

taken a turn for the worse, resulting in all the fluid in his

body being outside of his circulation, and pooling everywhere

else (legs, lungs etc.). We gave him some medicine to try and

offload the fluid, but it only made him better for a few hours.

Then whoever was on call at night gave him a whopping great dose

of the same stuff, causing him to collapse suddenly the next

morning when I came on duty. I mean, he was on his way out

anyway, but he didn't need the extra kick. Nathan*, our

registrar, happened to be on the ward at the time, and he (being

more experienced than me) had the presence of mind to phone the

relatives while Mr. Peters was still alive (but arguably on his

last legs) and get them to agree that CPR would be futile. By the

time his daughter arrived (about 20 minutes later) he was dead.

I think she knew, because she was already in tears when she

walked on to the ward. Nathan had been called away by then, so it

was just me, and it being a Sunday, I didn't even have the luxury

of a nurse to do the hand-holding and tissue-paper offering bits.

I got a nurse to sit her down in the relatives' room while I

gathered my thoughts and nicked the box of tissues I had spotted

at the dead man's bedside.

me: "hello, my name is Dr. Chan, i'm one of the doctors who was

looking after your father. Did you speak to Dr. Miller* on the

phone?"
her: "yes. he said my father was very sick....and that.... he

might not.... make it."
me: "yes, and in the time between you speaking to Dr. Miller and

arriving here, I'm afraid that he has died."

At the word 'died', she burst into tears. I offered her one of

the tissues, and held her hand. "I'm very sorry," I said, and

paused for her to sob, for what seemed like ages. "He just

slipped away," I continued, almost to fill the silence. "He

wouldn't have felt anything. His heart slowed gradually, and then

it stopped." I'm sure she didn't hear any of this. I could just

as well have muttered that he'd been run over by a giraffe in his

sleep. However, this only lasted about 5 minutes, and then she

became sensible again and said, "shall I go and see him?... oh...

I've never done this before, perhaps I should wait for the

others." "yes, sometimes it helps to have someone with you," I

said, knowing that i'd broken the news a bit too fast, and that

the nurses would still be removing the lines from the body, and

making it decent. "Do you want to just sit for a while?" She

nodded, and I left her.

I ended up examining a further 2 bodies that day. The next day, a

Monday, and so a 'normal' working day, we had a transfer from

A&E. An 80 year-old lady, she had just had a massive stroke. I

don't know how or why they get these patients into a CT scanner,

but they had done, and on CT she had had such a massive bleed

that it had shoved the right side of her brain over to the left

and out through the bottom of its vault - a situation definitely

not compatible with life. To make matters worse (and a whole lot

messier), she had aspirated some stomach contents into her lungs

and was pouring out horrid brown secretions from mouth and nose.

The relatives had been warned that it was a grave situation.

Our ward is 6 floors up from A&E, and before the nurses had even

properly received the patient, she had lost her pulse and become

completely unresponsive. I was called to see her. Unsurprisingly,

she was dead. I got the nurses to put the rellys in Sister's

office while I examined the body. I reflected on the events of

the day before. Maybe I should try and break the news a bit more

gently. Armed with a box of tissues, and accompanied by the burly

male nurse from A&E, I entered the little room and shut the door

behind us.

me: "Hello, my name is Dr. Chan. I'm one of the doctors working

on this ward. I heard that one of the doctors downstairs in A&E

has spoken to you?"
patient's sister:"Yes. Dr... oh, I've forgotten her name. Well,

she was a lovely doctor. She said my sister was very ill, she'd

had a stroke or something."
me (trying to look very serious):"yes, that's right. She had a

scan of her head and it showed a very big bleed into her brain."
pt.'s sis: "oh, Margaret* was always ever-so-healthy. she had a

few problems with her heart, but she would take it slowly and she

would be ok. she's had trouble with her breathing before, you

know..."
me: "Margaret had a big stroke. The blood put pressure on her

brain and that would have stopped her breathing. And then her

heart would have slowed and stopped..."
pt's sis (interrupting): "oh. you know, she would be wheezy

sometimes. they said it was her heart. what do you think would

have caused that?"
me (taking her hand): "Margaret's heart slowed and stopped today.

Margaret has died."

At this point, the old lady paused. She looked over at her son.

Then she started to cry.

I guess you can't win. Tell them directly, and they look shocked

(despite being forewarned). Tell them gently, and they just don't

get it. What is a doctor to do?

Dog

I went to the petrol station to get a pint of milk. And there,

tethered to the tire pump was an Afghan Hound. If I'd been in the

middle of Chelsea, this would hardly have been a surprise, but

here in central Reading, the word 'dog' conjures up the image of

an old lady's scruffy demi-poodle. It was the size of a small

pony, with a slender grey face and long, oat-coloured hair parted

neatly down its middle. It peered quizically at me - I felt a bit

stuck as I had only ever encountered pictures of them in

childrens' encyclopedias and it was quite overwhelming to meet

one in the flesh. Anyhow, I got my milk, and when I came out of

Costcutter, the hound was gone.

It (like everything else these days!) inevitably made me think of

work. I come across about 10 things (whether medical conditions,

bizarre family relationships etc.) every day that I've only ever

seen in a book, and my first reaction is inevitably 'oh look, it

really exists!' Then I struggle to conceal my amazement, as

patients don't like it when you haven't seen something before.

Even if you are only 25 and they are going on 90.

I see dead people

A most horrible thing happened today. (well, that along with about 50 most horrible things). My bleep goes off. "Can you come and certify a death please," says the nurse - her exact words. "I'll come as soon as I can," I say earnestly, which is my standard and unfeeling reply to all requests these days. My thoughts: signing a piece of paper saying someone is dead is last priority compared to the various things with live patients that I have to sort out. I've learned from previous mistakes on-call that you must Ignore The Voices - the most persistent nurse does not necessarily have the most urgent problem. So it is about 5 hours before I get round to 'certifying' the death. Unfortunately, it turns out that 'certify the death' in this hospital is slang for "can you examine this patient to confirm he is dead". So this poor dead guy lay behind the curtains in the middle of the ward waiting to be examined for 5 hours. Luckily for me there were no relatives.

The second body of the day was that of a woman on the Oncology ward. I was bleeped about this at 9:45, past the time that I am supposed to finish. But having learned my lesson, and knowing that the night person would be even busier than I had been, I decided to stop by the ward on my way out of the hospital to examine her. "She's behind that curtain there," said the nurse, trying to get me in as quickly as possible. The relatives were 10 minutes away by car, she said, and heading to the hospital now. But I would not be hurried, and insisted on reading the patient's notes first, as I had never met her before. When I did go to the bedside, I was very glad I had done that, because the patient had died of bleeding from a huge fungating tumour on her face. You could smell the tumour from the end of the bed, and apart from projecting for a good 2 inches from her face and being covered in fresh blood clot on its various projections, it had consumed most of her nose and right cheek. I could not prise open her right eye to examined for its inevitably fixed, dilated pupil. But of course, there was no doubt she was dead. Warm and smelly and dead. I was nearly sick all over the body.

Emerging from the curtains, I was immediately hassled to prescribe some painkillers and sedation for another patient. I wrote the requested drugs up and then bleeped the night person (a senior house officer) to hand over the leftover 'jobs' I hadn't managed to complete. There were a couple of sick patients I had dealt with earlier whom I hadn't had the time to review. The SHO rang back quite promptly. "Hi, its Sam, the on-call house officer. I need to go now, and have a lady on Ward 5 who needs review," I said, starting to relate the patient's history to her."That should have been done 3 hours ago!" she snapped. She went on to tell me off over the phone. She didn't seem to get that the whole point was, you treat the patient, then check back some hours later to see if they are any better, and if anything needs changing. In that particular patient I couldn't tell if it was heart failure or a worsening of pneumonia that was making her ill, so I had initiated treatment for both and taken some blood and ordered a chest x-ray. She was much better when I left her, but I needed someone to look at the xray and bloods to alter the treatment as needed. Maybe I was wrong, maybe I should have checked on her earlier. But that was no reason to shout at me. I hung up and left. If she didn't want to hear about sick patients from me, she could wait for the nurses to call her when the patients went off again. I'd had more than enough for one day. More than enough for a week even.

Despair

I will make no attempt to be coherent or grammatically or politically correct. This job has been pretty rubbish so far (I say 'so far' as I need to believe this in order to get up and go into work tomorrow). As the only house officer in the team, I get stuck with all the rubbish while I have 3 useless SHOs who know even less Medicine than my surgical SHOs did- in other words, I'm not learning anything from them and they are competing with me for what precious few learning opportunities there are. The nurses don't care about the patients - they actually grumble when you ask them to do more frequent blood pressure and pulse measurements on sick patients, the ward clerk doesn't file the notes properly and the whole attitude just pervades the ward. Which incidentally is a dump. And is located on the 6th floor, and 2 of the 3 lifts are broken. Patients are neglected - one man ate nothing for 10 days and the nurses didn't even bring it up on the ward rounds. It wasn't until I looked in the notes (he was admitted before I started work here) that we found out. More than half our patients are simply sitting on the ward waiting for a nursing home place - until they come down with a nasty hospital-acquired pneumonia. (But more about my gripes with nursing homes and granny-dumping another time.) Our ward is the only one without a doctors' office, which means that if you so much as sit down for 5 minutes to check blood or xray results or write a discharge letter, the nurses will come and hassle you for something that you've either already done or were going to do anyway. The doctors' mess is damp and dingy, its telephone resting on a chair with only three and a half legs. I've tried my best to be positive; I've smiled at and chatted with everyone, taken the time to go through the notes, sat and explained things to patients, explained things to nurses. Kept up with my log book of things I've learned (so far: how to manage hypercalcaemia, diabetic ketoacidosis, how to do a lumbar puncture). Its exhausting, and as I've said before, the emotional aspect of it is the most tiring. After a hard day of empathising with people you just get really irritable and its a struggle to even be reasonable. At least the recurring 'work' nightmares - when you go to sleep but your dream is just an extension of your work day and you wake up exhausted - have stopped now.

And at the end of the day, I come back to my room in the old block of the doctors' accommodation. All the other house officers are in the new block down the road - apparently my application was received late. But that was only because they sent it to the wrong address - twice. My room is heated by a bizarre system of pipes that runs all along the wall and that you can't adjust. With the result that the inside of the wardrobe is toasty but the rest of the room is usually freezing. There is no hot water in the basin or the shower, and the tap water is brown. There is not a single pot in the kitchen. But I could live with all that if it wasn't so lonely. Which is made worse by the fact that the phone line is dodgy - it just about works, but there is a loud ringing sound that drowns out all conversation, and slows my modem down to 40K. Have not felt like eating properly so have existed on instant noodles (cooked in my own non-stick frying pan) and breakfast cereal, and lots of fruit for vitamins. And bottled water of course. I had been too busy adjusting to my new job to realise how rubbish my living conditions were until yesterday. And yes, I did get on to the housing people and threatened to take it to the BMA, but they don't have a better room for me until Feb 28 so I have to put up with this for another two weeks. At least I have my mobile phone.

And so its back to work tomorrow. (and I am working this weekend too - I have three thirteen hour shifts to look forward to - not). What do patients know about the s**t doctors have to put up with just to be doctors.

oh whatever

cheered myself up a few days ago with the purchase of a bright pink electric toothbrush

Skiving the party

Just finished my second day on call in a row and all I want to do is go straight to bed. But there are pressures in this job that go beyond working hours. Everyone's at the pub as it is the last Thursday before we all change jobs. Friday is a bad day to be in hospital as half the house officers are hung over from the night before.

I really loathe nights out. Loitering in a smoke-filled room, insipid music blaring to fill the gaps in inane and meaningless conversation. The evening inevitably deteriorates as the more people drink, the better a time they think they are having. Can I be the only one with insight into the stupidity of the situation? These are people who are normally fairly intelligent and sensible - my colleagues, to be precise. Doctors by day, intoxicated cretins by night. I hate the pressure to fit in, to act like you're enjoying it, despite the fact that even a small amount of alcohol feels to me like a head-on collision with a large truck. I thought I'd stop caring about trying to be 'normal' when I was grown up. But I guess some things you don't grow out of.

2 out of 3

there's the old adage:
work, family and social life - you can quite easily maintain 2 of the 3, but it takes something superhuman to sustain them all.
and then there's this one:
the patient, the consultant (i.e. Boss/Reference) and yourself (i.e. sanity) - you can please 2 of the 3, but the third will suffer as a result

A Good Night

It started with an old lady in a faded yellow puffer jacket. Someone had parked her in her wheelchair and fluffy pink bedroom slippers right in front of the glass doors of the side entrance. "Do you want to go back inside?" I asked, seeing as I would have to push the wheelchair aside if I was going to get into the building. She stole a glance at the smoldering cigarette butt on the ground beside her. "Oh yes," she chirped, "I'm finished now." As I headed down the corridor towards A&E, she called out "Don't work too hard, doctor!"

How did she know. I bleeped Kay, the house officer who'd been on call in the daytime. "We're on Ward 1," she said, "doing a round with Mr. A." I knew something was up; registrars never do a round in the evening unless there's something interesting brewing - and I mean in the sense of tabloid newspaper rather than medical journal material. "You've got to see this." Behind the curtain lay a rather plump, middle-aged woman, her dark hair looking badly in need of a wash. Mr. A pulled up her nightdress to examine her belly. She had stuck a pair of nail scissors into her abdomen, right up to the hilt. Before he could lay a hand on her, and in front of a riveted 'audience', she pulled it right out. Due to the smallness of the scissors and the largeness of her abdominal wall, nothing happened. It was a bizarre moment."Theatre. Laparoscopy, maybe laparotomy and proceed. Psych review in the morning." Mr. A doesn't mince his words. He had 10 more patients to see and he wasn't going to be bogged down with "psychosocial issues".

[argh have to run! time for work... to be continued....]

Nightclub

Anna*, who is blonde and leggy, says he is "pervy". But I reckon Ben*, the A&E registrar, is rather like a bouncer - in both form and function. He is about six and a half feet tall, and as wide as a standard hospital trolley. He wears CK underpants (the band deliberately peeping from the top of his scrub bottoms), and a tight black T-shirt. His growl is part Carribean, part Essex. He is a lean, mean triaging machine, shunting patients to Orthopaedics or Medicine or ENT, or, best of all, Home - bouncing them back where they came from.


(*all names that appear on this blog have been changed!)

I am a panda

How can I still be alive? i've had about 3 hours' uninterrupted sleep in the last 48 hours. What part of "do not disturb" do the cleaners not understand?!
A sure sign that I am not feeling so good is an urge to write (and publish) bad poetry:

if you're tired and you know it
wear a smile
if you're grumpy and you know it
fake a smile
if you're unhappy and you know it
you would be a fool to show it
if you're exhausted and you know it
give a smile

argh 10minutes to another 11-hour night!! have to run

A guilt-free lunch

This is the dilemmma:
You are on call and have three patients waiting in A&E, all in considerable pain, one of them bleeding from the rectum, but none so sick as to be in danger of death. The A&E nurses are pressuring you to see the patients before they 'breach' the all-important 4 hour mark. However, you've just been on the ward sorting out a patient in heart failure, and that has taken the best part of an hour. Your bleep goes off - it is the ward nurses bleeping you about yet another patient - he has fallen over in the shower and hit his head on a hand rail, but seems fine apart from a large bruise. And here's the crunch - it's lunch time. If you've any medical experience you'll realise that the situation as described is perfect to take a break in - no lasting harm will be done if no action is taken within the next 10 minutes. What I have also learnt (from bitter experience), is that you have to grab these opportunities when they come, or you might not have the luxury of anything to eat (or drink) for the next 10 hours. (see 2 entries down)

So you take a break for lunch. But it is a furtive, hurried break. Even if the hospital canteen food had been tastier, you'd still end up choking it down. How can you sit down and relax, even for 5 minutes, when you know you've left people who need attention? And that's assuming your bleep doesn't go off (it inevitably does - I've never so much as eaten a sandwich without it sounding before I've swallowed the first mouthful). I feel so guilty about taking a break for lunch that I have to lie to patients that I am going to see another patient who is sicker. I guess there is a grain of truth in it.

my first death certificate, or a minute's silence for Mrs. B

my first thought was that my stethoscope must be broken - it took a second to remember that i'd been called by the nurses to confirm her death. Mrs. B had breathed her last, and as i peeled back her eyelids in turn, large inanimate pupils met my torch beam.

She had been tucked into bed and a crepe bandage wound round her head to hold her jaw shut. Under the dim reading light, the regulation pink hospital nightdress cast a rosy glow on her gaunt cheeks. A black and white photograph of her husband continued its vigil over her from the tray table. They must have been a handsome couple.

Mrs. B was 70, and had an advanced bladder cancer that had eaten into her vagina - she had bloody, fungating metastases - and blocked off her kidneys, causing them to fail. But as horrible as her disease was, I reckon she had died well. Early on, it was decided that she should have radiotherapy to keep the symptoms at bay, and stents put in to help the kidneys drain. She had a long line put in her arm so she didn't have to endure daily needlesticks for blood tests or medication. When it became apparent that her kidneys were failing despite all the treatment, a 'do not resuscitate' order was discussed while she was still lucid. She looked comfortable until the last, and was alert apart from her final 2 days, during which she drifted into a deepening sleep.